How a medical response team can help patients before they codeAt Baptist Memorial Hospital-Memphis, an innovative approach has reduced codes and mortality

Published in the November 2004 issue of Today’s Hospitalist

Call it a hunch, but physicians at Baptist Memorial Hospital-Memphis in Memphis, Tenn., thought that they might be missing signs of trouble in patients who were about to code.

Physicians and nurses noticed that in the hours before coding, some patients had experienced changes in their heart rate or blood pressure. The changes were often subtle, but they made clinicians wonder if there was something they could do to prevent the patients from taking a turn for the worse.

Physicians and nurses wanted to reach these patients before they coded, but they weren’t sure

The number of patients surviving codes has more than tripled to approximately 30 percent since the medical response team was created.

what to do. Then in 2003, they heard about the efforts of their counterparts in Australia.

After making similar observations about patients who coded, physicians at Austin Hospital in Victoria, Australia, created a medical emergency team. The idea was simple: Send ICU staff to the floors to evaluate patients who seemed to be having trouble. The concept quickly helped slash morbidity and mortality in the hospital’s patients.

Pre-code care

Soon after clinicians from Baptist Memorial heard about the Australian research at an Institute for Healthcare Improvement meeting, they began to implement their own version of the model. While they changed the name to medical response team, the goal--and many of the key concepts--remained the same.

First and foremost, says Jan Padgett, RN, Baptist Memorial’s ICU nurse manager, the hospital wanted to give the staff an opportunity to rescue patients prior to an emergency situation.

“We found out that usually six to eight hours prior to a code, the patient was having other problems, and those problems were going unrecognized,” Ms. Padgett says. “Maybe a nurse on the floor would call a physician but not have all the information to provide an accurate picture of the situation.”

To change that, Baptist Memorial encourages nurses on the floors to call the medical response team when they need some help with a patient. An ICU nurse and respiratory therapist then assess the patient and work with the floor nurse to come up with a treatment plan. They use a form known as the situation, background, assessment and recommendations (SBAR) tool to assess patients.

“The medical response team nurse is not going to take over the actual care of the patient,” Ms. Padgett explains. “She’s trying to help identify the best treatment for the patient.” Once the medical response team and nurse identify a plan, they call the attending to talk about how to proceed.

The hospital tested the concept during a three-day trial in August 2003. During that period, explains Sonny Golden, MD, medical director of Baptist Memorial’s intensive care units, the team received eight calls.

Four of the patients were eventually transferred to the ICU; the other four individuals received care on the floor. While the team potentially kept four patients out of the ICU who might have otherwise needed critical care, Dr. Golden adds that it brought four other individuals to the unit faster because of the team’s intervention.

Based on the pilot, the hospital quickly decided to make the medical response team a permanent feature at Baptist Memorial.

Fewer codes

The importance of the medical response team was also obvious to the ICU staff. The unit dedicated an RN on each shift to serve as the medical response team nurse. Ms. Padgett notes that designating a nurse to serve on the team has allowed the ICU to go even further in improving the hospital’s quality of care.

When the medical response team nurse isn’t busy working on the medical response team, for example, she follows up with patients who have been moved from the ICU to the floors. By keeping an eye on patients who have transferred out of the ICU, Ms. Padgett says, the nurse can make sure these patients are still doing well--and she can detect any problems before they become critical.

The team has two shifts: a day team that works with patients’ attending physicians, and a night team that uses an intensivist. Dr. Golden explains that because relatively few attendings work after hours, the hospital found it necessary to have a physician presence on the team between 6 p.m. and 7 a.m.

Today, the medical response team receives more than 1,000 calls a year. Hospital wide, codes have dropped 28 percent. And because the team typically sees patients before they code, most of the hospital’s codes now occur in the ICU, not in other areas of the hospital.

The medical response team’s results speak for themselves. Before the team was created, 60 percent of all codes took place outside of the ICU. Those statistics have been reversed. Dr. Golden also points out that the number of patients surviving codes has jumped, from about 8 percent to almost 30 percent since the team was created.

And the hospital’s mortality rate has dropped from a level of 120 in 2000 to a recent score of 75. (The hospital uses a measure known as the hospital specific mortality rate to track its mortality rate. A score of 100 indicates that a facility is in the top 50th percentile of mortality.) While Dr. Golden points out that the medical response team is not solely responsible for decreased mortality rates, he says it has made significant contributions to that goal.

Please-call policy

One critical factor in the team’s success is the hospital’s decision to encourage nurses to call whenever something seems awry. Nurses are told to call the team over something as simple as a change in mental status, a change in blood pressure or respiratory rate, heart rate, or oxygen saturation, Ms. Padgett says, or “just the feeling that they don’t know what’s going on with the patient.”

Dr. Golden says that the hospital consciously decided to avoid limiting calls from nurses. “If the cutoff for heart rate was 128 and the patient had a heart rate of 127,” he says, “they wouldn’t call. We left it very general on purpose because we didn’t want people to get confused about whether to call. We are relying on nurses’ sense that the patient’s status is deteriorating, so we use a broad set of triggers.”

Ms. Padgett says the strategy has paid off by bringing patients who need attention from the ICU to the unit while they’re still relatively healthy. “When the medical response team first began,” she explains, “we were intubating patients, putting them on vasoactive drips, and having to do a lot of things to get them stable. Now, fewer patients come to the ICU and need to be intubated.”

ICU throughput

Dr. Golden says the team has also helped the ICU turn around patients and transfer them to the floors more quickly.

In 2002, for example, the unit averaged 175 patients a month, with an average length of stay of about six days. Today, length of stay has decreased to about 4.4 days, and on some months the ICU admits as many as 250 patients.

Dr. Golden says that increased throughput allows physicians to admit patients to the ICU even if they’re not sure if a stay in the ICU is really needed.

“When we see a patient on the floor and we’re uncertain about which way the person is going, we have the luxury of putting the patient in the ICU for 12 or 24 hours,” he explains. “If you overreacted a little bit, you can just move that person out the next day. But in those cases where your hunch was right and things were going to get worse, you’ve already got the patient in an environment where you can monitor the changes so much better. Patients benefit from that.”